Client Information and Consent
Stacey Bales - Lash Artist
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Email
example@example.com
Birthdate
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Month
-
Day
Year
Date
How Did you hear about me, or who can I thank for referring you?
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Eyelash Service history
Have you had eyelash extensions previously
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Yes
No! I’m so excited!
If yes, did you have any issues with your previous eyelash extensions? Explain.
Have you had an eyelash lift or tint service in the last 8 weeks?
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Yes
No
If yes, date of last lift or tint service
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Month
-
Day
Year
Date
Medical History
*although helpful to me, to recognize contradictions for your scheduled service, medical information is optional to disclose
Check all that apply
Do you wear contact lenses?
Do you wear glasses?
Do you have frequent eye irritation, itching, or watery eyes?
Dry eyes
Permanent makeup
Eye lift
Chemotherapy in the last 6 months
Major surgery in the last 120 days
Pregnant or nursing
Are you sensitive or allergic to any of the following?
Bandaid or medical tape adhesive
Surgical glue or nail glue
Latex
Acrylic
Mascara or pencil eyeliner
Do you have any of the following conditions
Alopecia
Trichotillomania
Thyroid disease
Lupus
Diabetes
Glaucoma
Cataracts
History of styes
Conjunctivitis
Facial Eczema or psoriasis
Cancer
Hormone imbalance
Seasonal Allergies
Do you take any medications with the known side effect of causing dry brittle hair, or hair loss?
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Yes
No
Do you have any conditions, sensitivity, or allergy not listed, your lash technician should be aware of?
Eyelash service consent
I agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched. By signing this agreement, I consent to the placement and/or removal of the eyelash extensions by the certified eyelash extension professional, Stacey Bales. Although every precaution will be taken to ensure my safety and wellbeing before, during and after my lash extension application, I am aware of the following information and possible risks.
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Agree
I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.
Agree
I understand that in rare occasions there are risks associated with having artificial eyelashes. I further understand that in some circumstances temporary eye or skin irritation and discomfort may occur. This could include stinging, burning, redness or, watery eyes.
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Agree
I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
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Agree
I agree that if I experience any ill effects with my lashes that I will contact the certified eyelash extension professional that performed this procedure, as soon as possible. I understand my eyelash technician cannot give medical advice, and may recommend I seek medical treatment if deemed necessary.
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Agree
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and shed normally, making touch-up or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out
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Agree
I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned. There may be certain circumstances the Lash Technician advises against the length and style I have chosen, for the health of my natural lashes.
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Agree
I understand that because of the nature of eyelash extension service(s), my personal lifestyle, and care of the eyelash extensions, some natural lash damage could occur.
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Agree
I understand and consent to having my eyes closed and covered for the duration of the service. I understand that times may vary from 1-3 hours, depending on the type of service, and number of eyelashes applied.
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Agree
I understand and agree to the after-care instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions and I understand that it may cause the eyelash extensions to fall out and/or decrease the time the lashes will last. As well as the possibility to incur extra service expenses
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Agree
I understand and agree to the Lash service policy, cancellation/reschedule/no show policy , and payment for service policy, provided by the certified Lash Technician.
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Agree
I understand that no refunds are given for services rendered
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Agree
I understand that the card on file used to secure my initial appointment, will be charged if I fail to adhere to the cancellation/reschedule/no show policy provided to me by the Lash Technician.
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Agree
I Herby consent to and authorize Stacey Bales to preform eyelash extension services, at the establishment “Lollie’s Beauty Bar”. I have voluntarily elected to undergo this treatment/procedure/service. I understand and acknowledge that there are risks involved with the treatment I will be receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks, and other possible complications.I recognize there are no guaranteed results, and that independent results are dependent upon age, natural lash health (length, strength, and density), lifestyle, and proper or improper home care, between services. I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment of suggested home product/ post-treatment care, I will consult the Lash Technician immediately.I have, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects,or damages which might occur to me while I am undergoing this procedure. I do not hold the licensed professional Stacey Bales, or the establishment, responsible for any of my conditions that were present, but not disclosed at the time of the service, which may be affected by the service preformed. As well as any condition that may develop during or after the service. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash extension professional. I understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the eyelash extension application procedure.
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Submit
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